Treating hyperglycemia and diabetes with insulin therapy: transition from inpatient to outpatient care

Abstract

Context: Intensive insulin therapy is recommended to control glucose elevations in the critically ill and has been shown to significantly improve outcomes among hospital inpatients with acute hyperglycemia or newly diagnosed diabetes. Once discharged, the hyperglycemic patient may require ongoing outpatient care, most often under the attention of a primary care physician.

Evidence acquisition: The purpose of this review is to provide a background of in-hospital hyperglycemia management and discharge planning in preparation for continued outpatient care. Primary data sources were identified through a PubMed search (1990-2007) using keywords, such as diabetes, hyperglycemia, in-hospital, discharge, and insulin.

Evidence synthesis: Hyperglycemia protocols with strict glycemic goals have been shown to improve morbidity and mortality among critically ill inpatients. Discharge planning should prepare patients for self-care and give them the survival skills necessary to maintain glycemic control. In preparation for discharge, patients are usually transitioned from insulin infusions to subcutaneous insulin administered through an appropriate basal-prandial regimen.

Conclusion: A thorough understanding of hyperglycemia history and treatment will allow the primary care physician to deliver optimal diabetes care and thereby improve both short-term and long-term outcomes for those patients with critical illnesses and hyperglycemia or diabetes.

Figure 1

Most patients in the MICU spent time with hyperglycemia, even those with good glucose control at baseline; percentage of time (median and quartile bounds) above different glucose thresholds (within the first 120 hours of admission) are shown here. Reprinted with permission from Cely et al. Chest. 2004;126(3):879–887. A1C = glycated hemoglobin A1C; MICU = medical intensive care unit.

Figure 2

Patients with newly diagnosed hyperglycemia had significantly higher rates of in-hospital mortality than patients with normoglycemia or known diabetes, a pattern that occurred in both intensive care unit (ICU) and non-ICU patients. Reprinted with permission from Umpierrez et al. J Clin Endocrinol Metab. 2002;87(3):978–982. Copyright 2002, The Endocrine Society. *P < .01 vs both normoglycemia and known diabetes groups.

Figure 3

These Kaplan-Meier curves show that patients receiving intensive insulin therapy to maintain blood glucose between 80 mg/dL and 110 mg/dL had significantly improved survival both (A) while in the intensive care unit (ICU) and (B) throughout the hospital stay compared with patients on conventional therapy. Patients discharged alive from the ICU (Panel A) and from the hospital (Panel B) were considered to have survived. In both cases, the differences between the treatment groups were significant (survival in ICU, nominal P = .005 and adjusted P < .04; in-hospital survival, nominal P = .01). P values were determined with the use of the Mantel-Cox log-rank test. Reprinted with permission from Van den Berghe et al. N Engl J Med. 2001;345:1359–1367. Copyright © 2001 Massachusetts Medical Society. All rights reserved.

Figure 4

Treatment with a basal/prandial analog insulin regimen closely replicates endogenous insulin secretion patterns. Adapted with permission from Leahy JL, Cefalu WT, eds. Insulin Therapy. New York, NY: Marcel Dekker, Inc.; 2002:87–112.